PRINTER'S NO. 81
No. 96 Session of 2001
INTRODUCED BY FLEAGLE, NICKOL, MUNDY, CLARK, MANDERINO, VANCE,
JOSEPHS, L. I. COHEN, BELFANTI, T. STEVENSON, BEBKO-JONES,
MARSICO, FRANKEL, B. SMITH, BELARDI, RUBLEY, MAITLAND, DALEY,
HERSHEY, CAPPABIANCA, GEIST, HALUSKA, M. BAKER, STERN,
CORRIGAN, TIGUE, SCRIMENTI, SHANER, MAYERNIK, BARRAR,
BASTIAN, BENNINGHOFF, CLYMER, DAILEY, FAIRCHILD, HENNESSEY,
JADLOWIEC, R. MILLER, S. MILLER, NAILOR, PHILLIPS, SATHER,
SOLOBAY, STABACK, WILT AND ZUG, JANUARY 23, 2001
REFERRED TO COMMITTEE ON JUDICIARY, JANUARY 23, 2001
AN ACT
1 Amending Title 20 (Decedents, Estates and Fiduciaries) of the
2 Pennsylvania Consolidated Statutes, further providing for
3 advance directives for health care definitions and emergency
4 medical services; and providing for out-of-hospital
5 nonresuscitation.
6 The General Assembly of the Commonwealth of Pennsylvania
7 hereby enacts as follows:
8 Section 1. The definition of "declarant" in section 5403 of
9 Title 20 of the Pennsylvania Consolidated Statutes is amended to
10 read:
11 § 5403. Definitions.
12 The following words and phrases when used in this chapter
13 shall have the meanings given to them in this section unless the
14 context clearly indicates otherwise:
15 * * *
16 "Declarant." A person who makes a declaration in accordance
1 with this chapter. The term includes an emancipated minor.
2 * * *
3 Section 2. Section 5413 of Title 20 is amended to read:
4 § 5413. Emergency medical services.
5 [(a) Care given prior to declaration taking effect.--Nothing
6 in this chapter shall be construed to make the provisions of a
7 declaration apply to care given to a patient by emergency
8 medical services personnel prior to the declaration's becoming
9 operative under sections 5405 (relating to when declaration
10 becomes operative) and 5408 (relating to duty of physician to
11 confirm terminal condition).
12 (b) Care given after declaration takes effect.--The
13 provisions of a declaration shall apply to care given to a
14 patient by emergency medical services personnel after the
15 declaration becomes operative under sections 5405 and 5408 only
16 if:
17 (1) an original declaration, signed by the declarant or
18 other authorized person, is presented to the emergency
19 medical services personnel. The emergency medical services
20 personnel must immediately notify the medical command
21 physician of the presence of the declaration; or
22 (2) the medical command physician, based on prior
23 notification by the attending physician or other health care
24 provider that a valid and operative declaration exists,
25 directs the emergency medical service personnel according to
26 the provisions of the declaration.
27 (c) Uncertainty regarding validity of declaration.--
28 Emergency medical services personnel confronted with any
29 conflicting information regarding the patient's wishes for life-
30 sustaining treatment shall act according to the accepted
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1 treatment protocols and standards appropriate to their level of
2 certification.]
3 (a) General rule.--An emergency medical services provider
4 shall, in the course of providing care to a declarant, at all
5 times comply with the instructions of an authorized medical
6 command physician to withhold or discontinue cardiopulmonary
7 resuscitation.
8 (b) Applicability.--This section is applicable only in those
9 instances where an out-of-hospital DNR order is not in effect
10 under section 5404-A(a) (relating to orders, bracelets and
11 necklaces).
12 Section 3. Title 20 is amended by adding a chapter to read:
13 CHAPTER 54-A
14 OUT-OF-HOSPITAL NONRESUSCITATION
15 Sec.
16 5401-A. Short title of chapter.
17 5402-A. Legislative findings and intent.
18 5403-A. Definitions.
19 5404-A. Orders, bracelets and necklaces.
20 5405-A. Revocation.
21 5406-A. Liability.
22 5407-A. Effect on suicide and life insurance.
23 5408-A. Order optional.
24 5409-A. Preservation of existing rights.
25 5410-A. Emergency medical services.
26 5411-A. Pregnancy.
27 5412-A. Penalties.
28 5413-A. Severability.
29 § 5401-A. Short title of chapter.
30 This chapter shall be known and may be cited as the Do-Not-
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1 Resuscitate Act.
2 § 5402-A. Legislative findings and intent.
3 The General Assembly finds and declares as follows:
4 (1) Although cardiopulmonary resuscitation has saved the
5 lives of individuals about to experience sudden, unexpected
6 death, present medical data indicates that cardiopulmonary
7 resuscitation rarely leads to prolonged survival in
8 individuals with terminal illnesses in whom death is
9 expected.
10 (2) In many circumstances, the performance of
11 cardiopulmonary resuscitation may cause infliction of
12 unwanted and unnecessary pain and suffering.
13 (3) Existing emergency medical services protocols may
14 require emergency medical services personnel to proceed to
15 cardiopulmonary resuscitation when an individual is found in
16 a cardiac or respiratory arrest even if the individual has
17 completed a living will or advance directive indicating that
18 the individual does not wish to receive cardiopulmonary
19 resuscitation.
20 (4) The administration of cardiopulmonary resuscitation
21 by emergency medical services personnel to an individual with
22 an out-of-hospital do-not-resuscitate order offends the
23 dignity of the individual and conflicts with standards of
24 accepted medical practice.
25 (5) This chapter provides clear direction to emergency
26 medical services personnel and other health care providers in
27 regard to the performance of cardiopulmonary resuscitation.
28 (6) Nothing in this chapter is intended to condone,
29 authorize or approve mercy killing, euthanasia or aided
30 suicide or to permit any affirmative or deliberate act or
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1 omission to end life other than as defined in this chapter.
2 § 5403-A. Definitions.
3 The following words and phrases when used in this chapter
4 shall have the meanings given to them in this section unless the
5 context clearly indicates otherwise:
6 "Attending physician." The physician who has primary
7 responsibility for the treatment and care of the patient.
8 "Bracelet." An out-of-hospital do-not-resuscitate bracelet.
9 "Cardiopulmonary resuscitation." Cardiac compression,
10 invasive airway techniques, artificial ventilation,
11 defibrillation and other related procedures.
12 "Declarant." As defined in section 5403 (relating to
13 definitions).
14 "Declaration." As defined in section 5403 (relating to
15 definitions).
16 "Department." The Department of Health of the Commonwealth.
17 "DNR." Do not resuscitate.
18 "Emergency medical services provider." A health care
19 provider recognized under the act of July 3, 1985 (P.L.164,
20 No.45), known as the Emergency Medical Services Act. The term
21 includes those individuals recognized under 42 Pa.C.S. § 8331.2
22 (relating to good Samaritan civil immunity for use of automated
23 external defibrillator).
24 "EMS." Emergency medical services.
25 "Health care provider." A person who is licensed or
26 certified by the laws of this Commonwealth to administer health
27 care in the ordinary course of business or practice of a
28 profession. The term includes personnel recognized under the act
29 of July 3, 1985 (P.L.164, No.45), known as the Emergency Medical
30 Services Act. The term includes those individuals recognized
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1 under 42 Pa.C.S. § 8331.2 (relating to good Samaritan civil
2 immunity for use of automated external defibrillator).
3 "Incompetent." The lack of sufficient capacity for a person
4 to make or communicate decisions concerning himself.
5 "Invasive airway technique." Any advanced airway technique,
6 including endotracheal intubation.
7 "Life-sustaining treatment." Any medical procedure or
8 intervention that, when administered to a patient, will serve
9 only to prolong the process of dying or to maintain the patient
10 in a state of permanent unconsciousness. Life-sustaining
11 treatment shall include nutrition and hydration administered by
12 gastric tube or intravenously or any other artificial or
13 invasive means if the order of the patient so specifically
14 provides.
15 "Medical command physician." A licensed physician who is
16 authorized to give medical command under the act of July 3, 1985
17 (P.L.164, No.45), known as the Emergency Medical Services Act.
18 "Necklace." An out-of-hospital do-not-resuscitate necklace.
19 "Order." An out-of-hospital do-not-resuscitate order.
20 "Out-of-hospital do-not-resuscitate bracelet." A bracelet in
21 the standard format set forth in section 5404-A (relating to
22 orders, bracelets and necklaces), supplied by the department and
23 issued by the attending physician, which may be worn, at the
24 patient's option, to notify emergency medical services providers
25 of the presence of an order.
26 "Out-of-hospital do-not-resuscitate necklace." A necklace in
27 the standard format set forth in section 5404-A (relating to
28 orders, bracelets and necklaces), supplied by the department and
29 issued by the attending physician, which may be worn, at the
30 patient's option, to notify emergency medical services providers
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1 of the presence of an order.
2 "Out-of-hospital do-not-resuscitate order." An order in the
3 standard format set forth in section 5404-A (relating to orders,
4 bracelets and necklaces), supplied by the department and issued
5 by the attending physician, directing emergency medical services
6 providers to withhold cardiopulmonary resuscitation from the
7 patient in the event of respiratory or cardiac arrest.
8 "Out-of-hospital do-not-resuscitate patient." Any of the
9 following:
10 (1) An individual:
11 (i) who is in a terminal condition; and
12 (ii) who, pursuant to section 5404-A(a) (relating to
13 orders, bracelets and necklaces), possesses and in any
14 manner displays or causes to be displayed for emergency
15 medical services providers an apparently valid order,
16 bracelet or necklace.
17 (2) A declarant:
18 (i) whose declaration has become operative under
19 section 5405(2) (relating to when declaration becomes
20 operative); and
21 (ii) who, pursuant to section 5404-A(a), possesses
22 and in any manner displays or causes to be displayed for
23 emergency medical services providers an apparently valid
24 order, bracelet or necklace.
25 "Patient." An out-of-hospital do-not-resuscitate patient.
26 "Permanently unconscious." A medical condition that has been
27 diagnosed in accordance with currently accepted medical
28 standards and with reasonable medical certainty as total and
29 irreversible loss of consciousness and capacity for interaction
30 with the environment. The term includes, without limitation, a
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1 persistent vegetative state or irreversible coma.
2 "Person." An individual, corporation, partnership,
3 association or Federal, State or local government or
4 governmental agency.
5 "Terminal condition." An incurable and irreversible medical
6 condition in an advanced state caused by injury, disease or
7 physical illness which will, in the opinion of the attending
8 physician, to a reasonable degree of medical certainty, result
9 in death regardless of the continued application of life-
10 sustaining treatment.
11 § 5404-A. Orders, bracelets and necklaces.
12 (a) Issuance.--An attending physician, upon the request of
13 an individual who is at least 18 years of age, has graduated
14 from high school or has married, or the individual's surrogate
15 if the surrogate is so authorized, shall issue to the individual
16 an order, and may issue at the request of the patient or the
17 patient's surrogate a bracelet or necklace supplied by the
18 department. The patient may, at the patient's option, wear the
19 bracelet or display the order or necklace to notify emergency
20 medical services providers of the patient's do-not-resuscitate
21 status.
22 (b) Format of order.--The department shall, with the advice
23 of the Pennsylvania Emergency Health Services Council and with
24 the assistance of the regional emergency medical services
25 councils, make available within 180 days of the effective date
26 of this subsection standard orders for issuance to patients by
27 attending physicians of this Commonwealth. The form of the order
28 shall contain, but not be limited to, the following:
29 PENNSYLVANIA OUT-OF-HOSPITAL
30 DO-NOT-RESUSCITATE ORDER
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1 Patient's full legal name:
2 I, the undersigned, state that I am the attending
3 physician of the patient named above. The above-named
4 patient has requested this order and I have made the
5 determination that this patient is in a terminal
6 condition and eligible for an order.
7 I direct any and all emergency medical services
8 personnel, commencing on the effective date of this
9 order, to withhold cardiopulmonary resuscitation (cardiac
10 compression, invasive airway techniques, artificial
11 ventilation, defibrillation and other related procedures)
12 from the patient in the event of the patient's
13 respiratory or cardiac arrest. I further direct such
14 personnel to provide to the patient other medical
15 interventions, such as intravenous fluids, oxygen or
16 other therapies necessary to provide comfort care or to
17 alleviate pain, unless directed otherwise by the patient
18 or the emergency medical services provider's authorized
19 medical command physician.
20 Signature of attending physician:
21 Printed name of attending physician:
22 Dated:
23 Attending physician's emergency telephone number:
24 Signature of patient (if capable of making informed
25 decisions):
26 I, the undersigned, hereby direct that in the event
27 of my cardiac and/or respiratory arrest, efforts at
28 cardiopulmonary resuscitation not be initiated. I
29 understand that I may revoke these directions at any time
30 by giving verbal instructions to the emergency medical
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1 services providers, by physical cancellation or
2 destruction of this form or my bracelet or necklace, or
3 by simply not displaying this form or the bracelet or
4 necklace for my EMS caregivers.
5 Signature of surrogate (if patient is incapable of
6 making informed decisions):
7 I, the undersigned, hereby certify that I am
8 authorized to execute this order on the patient's behalf
9 by virtue of having been designated as the patient's
10 surrogate and/or by virtue of my relationship to the
11 patient (specify relationship: _________________). I
12 hereby direct that in the event of the patient's cardiac
13 and/or respiratory arrest, efforts at cardiopulmonary
14 resuscitation not be initiated.
15 (c) Format of bracelet.--The department shall, with the
16 advice of the Pennsylvania Emergency Health Services Council and
17 with the assistance of the regional emergency medical services
18 councils, make available within 180 days of the effective date
19 of this subsection standard bracelets for issuance to patients
20 by attending physicians. The bracelets shall be uniform in
21 design and shall, at a minimum, on the face clearly indicate
22 OUT-OF-HOSPITAL DNR and the name of the patient and attending
23 physician, as well as the dated signature of the attending
24 physician.
25 (d) Format of necklace.--The department shall, with the
26 advice of the Pennsylvania Emergency Health Services Council and
27 with the assistance of the regional emergency medical services
28 councils, make available within 180 days of the effective date
29 of this subsection standard necklaces for issuance to patients
30 by attending physicians. The necklaces shall be uniform in
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1 design and shall, at a minimum, on the face clearly indicate
2 OUT-OF-HOSPITAL DNR and the name of the patient and attending
3 physician, as well as the dated signature of the attending
4 physician.
5 § 5405-A. Revocation.
6 (a) Patient.--If a patient has obtained an order, only the
7 patient may revoke the patient's DNR status.
8 (b) Surrogate.--If a surrogate has obtained an order, the
9 patient or the surrogate may revoke the patient's status.
10 (c) Manner.--Revocation under this section may be done at
11 any time without regard to the patient's physical or mental
12 condition and in any manner, including verbally or by destroying
13 or not displaying the order, bracelet or necklace.
14 § 5406-A. Liability.
15 (a) General rule.--No physician, emergency medical services
16 provider or other health care provider who, consistent with this
17 chapter, causes or participates in the initiating, continuing,
18 withholding or withdrawal of life-sustaining treatment or
19 cardiopulmonary resuscitation from a patient shall, as a result
20 of such action, be subject to criminal or civil liability or be
21 found to have committed an act of unprofessional conduct if the
22 attending physician, health care provider or emergency medical
23 services provider has followed the patient's wishes as expressed
24 earlier by the patient in the form of a declaration or order
25 executed pursuant to this chapter.
26 (b) Absence of order, bracelet or necklace.--The absence of
27 an order, bracelet or necklace by a patient shall not give rise
28 to any presumption as to the intent of the patient to consent to
29 or to refuse the initiation, continuation or termination of
30 life-sustaining treatment.
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1 § 5407-A. Effect on suicide and life insurance.
2 (a) Criminal effect.--The withholding or withdrawal of life-
3 sustaining treatment from a patient in accordance with the
4 provisions of this chapter shall not, for any purpose,
5 constitute suicide or homicide.
6 (b) Life insurance.--The making of or failure to make an
7 order in accordance with this chapter shall not affect in any
8 manner the sale, procurement or issuance of any policy of life
9 insurance nor shall it be deemed to modify the terms of an
10 existing policy of life insurance. No policy of life insurance
11 shall be legally impaired or invalidated in any manner by the
12 withholding or withdrawal of life-sustaining treatment from an
13 insured patient, notwithstanding any term of the policy to the
14 contrary.
15 § 5408-A. Order optional.
16 No physician or other health care provider and no health care
17 service plan, health maintenance organization, insurer issuing
18 disability insurance, self-insured employee welfare benefit
19 plan, nonprofit hospital plan or Federal, State or local
20 government sponsored or operated program may:
21 (1) require any person to execute an order as a
22 condition for being insured for or receiving health care
23 services; or
24 (2) charge any person a different rate or fee whether or
25 not the person executes or has executed an order.
26 § 5409-A. Preservation of existing rights.
27 The provisions of this chapter shall not impair or supersede
28 any existing rights or responsibilities not addressed in this
29 chapter.
30 § 5410-A. Emergency medical services.
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1 (a) Medical command instructions.--Notwithstanding the
2 absence of an order, bracelet or necklace pursuant to this
3 section, emergency medical services providers shall at all times
4 comply with the instructions of an authorized medical command
5 physician to withhold or discontinue resuscitation.
6 (b) Effect of order, bracelet or necklace.--
7 (1) Emergency medical services providers are authorized
8 to, and shall, comply with an order if made aware of the
9 order by examining a bracelet, a necklace or the order
10 itself.
11 (2) Emergency medical services providers shall provide
12 other medical interventions necessary and appropriate to
13 provide comfort and alleviate pain, including intravenous
14 fluids, medications, oxygen and any other intervention
15 appropriate to the level of the certification of the
16 provider, unless otherwise directed by the patient or the
17 emergency medical services provider's authorized medical
18 command physician.
19 (3) As used in this subsection, the term "comply" means:
20 (i) to withhold cardiopulmonary resuscitation from
21 the patient in the event of respiratory or cardiac
22 arrest; or
23 (ii) to discontinue and cease cardiopulmonary
24 resuscitation in the event the emergency medical services
25 provider is presented with an order or discovers a
26 necklace or bracelet after initiating cardiopulmonary
27 resuscitation.
28 (c) Uncertainty regarding validity or applicability of
29 order, bracelet or necklace.--
30 (1) Emergency medical services providers who in good
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1 faith are uncertain about the validity or applicability of an
2 order, bracelet or necklace shall render care in accordance
3 with their level of certification.
4 (2) Emergency medical services providers who act under
5 paragraph (1) shall not be subject to civil or criminal
6 liability or administrative sanction for failure to comply
7 with an order under this section.
8 (d) Recognition of other states' orders.--Emergency medical
9 services or out-of-hospital DNR orders, bracelets or necklaces
10 valid in states other than this Commonwealth shall be recognized
11 in this Commonwealth to the extent that these orders, bracelets
12 or necklaces are consistent with the laws of this Commonwealth.
13 Emergency medical services providers shall act in accordance
14 with the provisions of this section when encountering a patient
15 with an apparently valid EMS or out-of-hospital DNR form,
16 bracelet or necklace issued by another state. Emergency medical
17 services providers acting in good faith under this section shall
18 be entitled to the same immunities and protections that would
19 otherwise be applicable.
20 § 5411-A. Pregnancy.
21 (a) General rule.--Notwithstanding the existence of an order
22 or direction to the contrary, life-sustaining treatment,
23 cardiopulmonary resuscitation, nutrition and hydration must be
24 provided to a pregnant patient unless, to a reasonable degree of
25 medical certainty as certified on the patient's medical record
26 by the attending physician and an obstetrician who has examined
27 the patient, life-sustaining treatment, nutrition and hydration:
28 (1) will not maintain the pregnant patient in such a way
29 as to permit the continuing development and live birth of the
30 unborn child;
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1 (2) will be physically harmful to the pregnant patient;
2 or
3 (3) would cause pain to the pregnant patient which
4 cannot be alleviated by medication.
5 (b) Pregnancy test.--Nothing in this section shall require a
6 physician to perform a pregnancy test unless the physician has
7 reason to believe that the patient may be pregnant.
8 (c) Payment of expenses by Commonwealth.--
9 (1) In the event that treatment, cardiopulmonary
10 resuscitation, nutrition or hydration are provided to a
11 pregnant patient, notwithstanding the existence of an order
12 or direction to the contrary, the Commonwealth shall pay all
13 usual, customary and reasonable expenses directly and
14 indirectly incurred by the pregnant patient to whom such
15 treatment, nutrition and hydration are provided.
16 (2) The Commonwealth shall have the right of subrogation
17 against all moneys paid by any third-party health insurer on
18 behalf of the pregnant patient.
19 (3) The expenditures incurred on behalf of the pregnant
20 patient shall constitute a grant and no lien shall be placed
21 upon the property of the pregnant patient, her estate or her
22 heirs.
23 § 5412-A. Penalties.
24 Any person who intentionally conceals, cancels, defaces,
25 obliterates or damages the order, bracelet or necklace of
26 another without the consent of the patient commits a felony of
27 the third degree. Any person who falsifies or forges the order,
28 bracelet or necklace of another, or conceals or withholds
29 personal knowledge of a revocation as provided in section 5405-A
30 (relating to revocation), with the intent to cause a withholding
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1 or withdrawal of life-sustaining treatment contrary to the
2 wishes of the patient and, because of such an act, directly
3 causes life-sustaining treatment to be withheld or withdrawn and
4 death to be hastened shall be subject to prosecution for
5 criminal homicide as provided in 18 Pa.C.S. Ch. 25 (relating to
6 criminal homicide). Any person who intentionally, by undue
7 influence, fraud or duress, causes a person to execute an order
8 pursuant to this chapter commits a felony of the third degree.
9 § 5413-A. Severability.
10 The provisions of this chapter are severable, and, if any
11 word, phrase, clause, sentence, section or provision of this
12 chapter is for any reason held to be unconstitutional, the
13 decision of the court shall not affect or impair any of the
14 remaining provisions of this chapter. It is hereby declared as
15 the legislative intent that this chapter would have been adopted
16 had such unconstitutional word, phrase, clause, sentence,
17 section or provision thereof not been included herein.
18 Section 4. The Department of Health shall, with the advice
19 of the Pennsylvania Emergency Health Services Council and with
20 the assistance of the regional emergency medical services
21 councils, develop and make available to health care providers
22 recognized under the act of July 3, 1985 (P.L.164, No.45), known
23 as the Emergency Medical Services Act, including those
24 individuals recognized under 42 Pa.C.S. § 8331.2, within 180
25 days of the effective date of this act, educational materials
26 relating to the implementation of the provisions of this act.
27 The department shall also cause the requirements of this act to
28 be included as part of the curricula for health care providers
29 recognized under the Emergency Medical Services Act.
30 Section 5. The Department of Health may contract with any
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1 public or private entity to facilitate all or part of its
2 responsibilities under 20 Pa.C.S. Ch. 54 or 54-A.
3 Section 6. The Department of Health, upon the conclusion of
4 at least one public hearing, shall publish interim regulations
5 in the Pennsylvania Bulletin within 120 days of the effective
6 date of this act. The interim regulations shall not be subject
7 to the act of July 31, 1968 (P.L.769, No.240), referred to as
8 the Commonwealth Documents Law, or to the act of June 25, 1982
9 (P.L.633, No.181), known as the Regulatory Review Act. The
10 interim regulations shall be effective until final regulations
11 are promulgated by the department. Final regulations shall be
12 promulgated no later than 18 months following the effective date
13 of this act.
14 Section 7. This act shall take effect in 60 days.
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